General Approach to Trauma Patients

1 Which trauma patients need to be admitted to the intensive care unit (ICU)?

Patients who are receiving mechanical ventilation or require vasopressor support will obviously be admitted to the ICU. As care has shifted to nonoperative management of many injuries, the ability to closely monitor patients is critical. For example, a patient with a grade 4 splenic laceration who undergoes splenectomy may be able to be managed after surgery on a regular ward, whereas that same patient, if managed without surgery, would likely require closer observation in an ICU.

Examples of trauma patients who may not meet clear-cut “critical care” criteria but who demand close serial observation that is often best carried out in an ICU include those with potential extremity compartment syndrome, nonoperative high-grade solid-organ injuries, significant closed-head injuries, and nonoperative penetrating abdominal trauma. Depending on local capacity a highly monitored observation or “step-down” unit may also be appropriate for these types of patients. If in doubt, admit them to a more-monitored rather than less-monitored setting.

2 What is the top priority when a trauma patient first presents?

Airway evaluation and management are the critical starting point for the evaluation of any trauma patient. Airway compromise is the most important cause of early preventable death in trauma patients. The airway must be secured before further evaluation or treatment is undertaken.

3 How is the airway managed in trauma patients?

Airway management is discussed thoroughly in Chapter 14, but trauma patients can pose a unique set of airway management challenges. Maxillofacial, laryngotracheal, and neck injury; intracranial hypertension; hemodynamic instability; thermal injury to the airway; and the need for maintaining in-line cervical spine stabilization are common conditions that can complicate airway management in trauma.

All trauma care providers should have experience with airway evaluation and management from manual airway maneuvers (e.g., jaw thrust, chin lift), to the use of mechanical airway devices (oropharyngeal and nasopharyngeal airways), to bag-mask ventilation, to rapid-sequence endotracheal intubation, to the use of airway adjuncts such as the bougie or laryngeal mask airway, to establishing a surgical airway. A general algorithm for trauma airway management is shown in Figure 2-1.

Figure 2-1 Algorithm for airway management in trauma. O₂sat, Oxygen saturation.

4 What are the most important causes of hypotension in the trauma patient?

Hemorrhagic shock—bleeding—is the most common cause of hypotension in the trauma patient. A vigorous search for bleeding is the key to the initial evaluation of any trauma patient with hypotension. Even a single episode of hypotension (systolic blood pressure [SBP] < 100-110 mm Hg) should be considered a potential harbinger of serious injury requiring interventional hemorrhage control. Methods for rapid localization of hemorrhage are discussed in Question 5.

Obstructive shock is that caused by tension pneumothorax or pericardial tamponade. Pericardial tamponade is usually diagnosed with the help of ultrasound examination. Tension pneumothorax is usually diagnosed clinically by mechanism and physical examination. Occasionally ultrasound or chest radiographic examination may be of assistance, but one should never wait to obtain these studies when the diagnosis is suspected.

Spinal shock is a form of neurogenic shock that occurs because of the loss of sympathetic tone and peripheral vasodilation that occurs with high (typically T4 level or above) spinal cord injuries. It should be suspected when the patient has had a compatible mechanism of injury, the hypotension is accompanied by bradycardia, and results of the neurologic examination are consistent (lower extremity paralysis, loss of rectal tone, and a compatible sensory level).

Cardiogenic shock may result from traumatic cardiac contusion or occasionally from preexisting cardiac pathologic condition (coronary disease, valvular lesions, congestive heart failure) in patients with other, noncardiac trauma.

5 How can I rapidly identify the source of bleeding in hemorrhagic shock?

Delayed control of bleeding ranks with airway compromise as a major preventable cause of trauma death. To be controlled, the source of bleeding must be rapidly identified. Hypotension due to hemorrhage typically does not occur until a trauma patient has lost 30% to 40% of his or her blood volume. This quantity of blood can be lost only into a limited number of places. The most important of these places are, externally, the chest, the abdomen, the retroperitoneum, and occasionally the thighs. Patients with hypotension should not undergo prolonged imaging such as computed tomography (CT), and all these potential areas of bleeding must usually be evaluated in the emergency department in a matter of minutes. This is possible with reasonable sensitivity for major hemorrhage with use of a combination of physical examination, ultrasound scan, and plain radiography, all modalities that are widely and quickly available.

Physical examination is the most important tool for identifying external sources of bleeding. External bleeding is often missed or underappreciated when it is due to scalp wounds (which can result in significant blood loss); wounds in the back or axillae, which may be missed by a cursory examination; or mangled extremities, which may be diffusely oozing.

Physical examination and chest radiographic examination are the keys to identifying thoracic bleeding. Both can be done quickly. Ultrasound may be a useful adjunct (see extended focused abdominal sonography for trauma [E-FAST] later). If reasonable suspicion exists for intrathoracic bleeding, tube thoracostomy may be both diagnostic and therapeutic.

The abdomen is usually evaluated by FAST. If it cannot be performed, or is technically limited, diagnostic peritoneal aspiration or lavage is an alternative.

The retroperitoneum cannot be directly evaluated without CT, but most hemodynamically significant retroperitoneal bleeding is the result of pelvic fractures, which can be detected on a plain radiograph of the pelvis. Although retroperitoneal bleeding due to pelvic fractures generally correlates with the severity of the fracture, even relatively minor fractures may occasionally produce major hemorrhage. Similarly, femur fractures, especially if bilateral, suggest the possibility of significant hemorrhage into the thighs.

6 What is the role of the FAST examination in evaluating the trauma patient with hemodynamic instability?

The FAST examination has become a standard part of the evaluation of the trauma patient. It involves an ultrasound examination of four locations: the right and left upper quadrants of the abdomen, the pelvis, and the pericardium. The primary role of FAST is to evaluate for hemoperitoneum in patients with blunt trauma who are hemodynamically unstable. In these patients, when no other explanation for hypotension exists, positive FAST examination results can quickly identify the need for laparotomy, saving the time that might otherwise be spent obtaining more involved imaging such as CT. Patients with blunt trauma who are hemodynamically stable but have intraabdominal fluid identified on FAST should not be rushed to the operating room but should undergo CT imaging. Many common injuries, such as splenic and liver lacerations, which can result in positive FAST examination results, do not require surgical exploration and can be better defined on CT, which is safe to perform if the patient is hemodynamically stable. FAST can also identify pericardial tamponade. E-FAST includes sonography of the thorax to assess for hemothorax or pneumothorax. In many centers, FAST is routinely performed even in stable patients to establish a baseline for comparison if the patient’s condition later deteriorates.

7 What is damage control resuscitation?

Damage control resuscitation refers to the practice of administering blood products early in the course of resuscitation of patients with massive hemorrhage (anticipated need for > 10 U packed red blood cell [PRBC] transfusion) to limit the coagulopathy associated with crystalloid administration or isolated PRBC transfusion. Observational data from the battlefield and civilian trauma centers suggest that early administration of fresh frozen plasma (FFP) and platelets reduces mortality and postoperative transfusion after major hemorrhage. The optimal ratio of PRBC/FFP/platelets that should be administered in the setting of massive bleeding is a matter of debate, and no controlling evidence is available. The U.S. Army has adopted a policy of administering these products in a 1:1:1 ratio for battlefield casualties requiring massive transfusion. Other investigators have achieved reductions in mortality by instituting a 4:2:1 ratio in place of unstructured transfusion. Whatever the exact ratio chosen, it is ideal to have in place a massive transfusion protocol that allows the blood bank to deliver blood products rapidly in a fixed ratio. This allows the desired ratio to be achieved and simplifies the process of care when caring for these critically ill patients. Massive transfusion protocols using the different product ratios described earlier have been shown to reduce mortality in case-controlled studies. Whenever this quantity of transfusion is required, the use of a combination rapid transfuser–fluid warmer is highly recommended to prevent hypothermia. It should be reemphasized that these guidelines apply only to the massively transfused patient and that excessive blood products in patients with minimal hemorrhage may even be harmful.

8 What is hypotensive resuscitation?

Hypotensive resuscitation, also known as permissive hypotension, refers to the principle of gaining hemorrhage control before restoration of euvolemia and normal blood pressure. The most important steps in treatment of the bleeding trauma patient are identifying the source of bleeding and stopping it. If vigorous fluid resuscitation proceeds before these goals have been met, hemodilution, hypothermia, and increased blood pressure may actually work to increase bleeding by causing coagulopathy and by popping the clot. Hypotensive resuscitation, in which a minimal blood pressure to provide end-organ perfusion is maintained until definite hemorrhage control (whether surgical, endovascular, or otherwise), has been associated with improved survival in patients with penetrating torso trauma.

9 When fluid resuscitation of the bleeding trauma patient is begun, how should it be carried out?

Adequate intravenous access is a prerequisite for large-volume resuscitation. Large-bore (14 gauge or 16 gauge) peripheral intravenous cannulas are ideal because they can be placed quickly and have a large diameter and short length, which allows rapid infusion. Even larger-bore peripheral and central lines (7.5 F to 8.5 F) allow still more rapid infusion though may be more time-consuming to place. Multiport central lines are not appropriate for significant volume resuscitation, because their small diameter and length result in slow rates of infusion. When large-volume transfusion is anticipated, all effort should be made to use a rapid infuser–fluid warmer system to reduce coagulopathy due to hypothermia. If bleeding patients are taken to the operating room, a cell saver suction system can reduce transfusion requirements.

10 What is damage control surgery?

The term damage control comes from the U.S. Navy, in which it refers to the ability of a ship to sustain damage but be adequately repaired in the field to allow completion of its mission, with definitive repair deferred until return to port. Damage control surgery refers to operations performed in patients whose condition is unstable to control hemorrhage and limit contamination, without completing definitive repair of all injuries. This commonly includes maneuvers such as resecting bowel without performing an anastomosis, placing temporary vascular shunts without performing definitive vessel repair, packing for control of hemorrhage, and the use of rapid temporary closure techniques. Damage control operations are followed by a period of resuscitation in the ICU, during which physiologic homeostasis is restored by the correction of coagulopathy, hypothermia, electrolyte abnormalities, and other derangements. Finally, reoperation for definitive repair of injuries is the final step.

11 What are the signs of abdominal compartment syndrome, and how is it managed?

Abdominal compartment syndrome occurs when high intraabdominal pressure causes end-organ compromise. Abdominal compartment syndrome in trauma usually occurs because of massive fluid resuscitation, which causes visceral edema, occasionally compounded by an intraabdominal hematoma, or packs placed for hemostasis. A tense distended abdomen, respiratory distress (or high peak inspiratory pressures if mechanically ventilation is used), and oliguria constitute the classic clinical triad of abdominal compartment syndrome. This triad is often accompanied by hypotension. Respiratory distress and high peak inspiratory pressures result from the abdominal pressure pushing up on the diaphragm, oliguria results from compression of the renal vein disturbing perfusion to the kidney and causing acute kidney injury, and hypotension is caused by decreased venous return via the inferior vena cava. When abdominal compartment syndrome is suspected, intraabdominal pressure can be measured by transducing the pressure measured via a bladder catheter. An intraabdominal pressure > 20 mm Hg in the proper clinical setting is highly suggestive of abdominal compartment syndrome. Although medical management with diuresis (which may reduce visceral edema) and paralysis (which increases abdominal wall compliance) may occasionally be sufficient, definitive therapy requires surgical decompression of the abdomen.

12 How can I clear the cervical spine?

The cervical spine should be immobilized in blunt trauma patients who have had significant force to the head or neck. In awake patients with an intact sensorium who can focus on the examination, the cervical spine can be cleared by physical examination alone. The midline bony structures of the neck from C1 to C7 should be carefully palpated. Next, the examiner should push down on the top of the patient’s head, axially loading the cervical spine. Finally, the patient should be asked to flex and extend the neck and turn the head from side to side. If all these maneuvers can be completed without eliciting pain or tenderness, cervical spinal immobilization is not necessary. If pain or tenderness is identified at any point, a cervical collar should be reapplied immediately, and a CT scan of the cervical spine performed.

In patients who are not clinically examinable, radiographic evaluation should begin with a CT scan of the cervical spine. Our practice is to discontinue cervical immobilization if the attending radiologist and trauma surgeon agree that the CT scan is completely normal, meaning not only is there no fracture but there is no abnormality of any kind, including no prevertebral soft tissue swelling, and no loss of normal lordosis. This is an area of some debate, and other practitioners recommend routine magnetic resonance imaging before discontinuing cervical immobilization in unexaminable patients.

13 Should patients with spinal cord injury receive steroids?

Patients with acute blunt spinal cord injury may derive slight functional benefit from early administration of high-dose steroids, though their use is debated. If the decision is made to treat with steroids, methylprednisolone should be administered with a bolus of 30 mg/kg and an infusion started at 5.4 mg/kg per hour. If the first dose is administered within 3 hours of injury, the infusion should be continued for 24 hours. If the first dose is administered between 3 and 8 hours after injury, the infusion should be continued for 48 hours, and if the first dose cannot be administered within 8 hours of injury it should not be administered at all.

14 How is closed-head injury managed?

The following are the key management principles for patients with closed-head injury:

Although it is difficult to demonstrate benefit for each of these interventions individually, when instituted as a bundle they can result in a decrease in mortality for patients with brain injury.

When discrete traumatic mass lesions such as acute subdural or epidural hemorrhage occur, these should be surgically evacuated. No benefit is proved for decompressive craniotomy for patients with persistently elevated intracranial pressure without a surgically amenable mass lesion.

15 What are the options for treating massive bleeding from pelvic fractures?

Pelvic fractures can often be appreciated on physical examination when instability of the pelvic ring is detected. A plain anteroposterior radiographic film of the pelvis, easily obtained in the trauma bay, confirms the diagnosis. Pelvic fractures may be associated with massive bleeding from the rich pelvic plexus of veins and occasionally from associated pelvic arterial structures. Because the bleeding typically occurs diffusely from multiple sources, it is not possible to identify and ligate the bleeding vessels. Arrest of hemorrhage relies on three primary modalities:

These techniques are best performed simultaneously in an operating room capable of accommodating endovascular intervention.

16 When is chemical deep venous thrombosis (DVT) prophylaxis safe in traumatically injured patients?

Trauma patients in general are at high risk for the development of venous thrombosis and thromboembolism, and so prompt initiation of prophylaxis against DVT is important. The American College of Chest Physicians recommends immediate initiation of thromboprophylaxis with low-molecular-weight heparin in all trauma patients except those with a contraindication because of active bleeding or a high risk of clinically important bleeding. What exactly comprises a contraindication in trauma remains subjective. Retrospective data suggest that chemical prophylaxis is safe in patients whose condition is stable, even with closed-head and solid-organ injuries, and that chemical DVT prophylaxis can be safely initiated 24 to 72 hours after injury in these patients. Large randomized trials are still needed to better define the best thromboprophylaxis regimen and the optimal timing for initiation of thromboprophylaxis in patients with major trauma.